Community Enhanced Recovery Team (CERT) – Sheffield – Winners #MHAwards19

Without the provision of CERT, the service users we work with would have remained in out of city locked rehabilitation hospitals, often many miles away from their homes, family & community

Our close partnership with South Yorkshire Housing Association; through working together we have recognised the importance of a stable place and giving a sense of ownership and safety to a person in order for people to build on their skills and confidence in living in the community and being able to work on other aspects of their lives.

By putting staff wellbeing at the heart of what we do and using a whole team approach in all aspects of clinical provision and service development and quality improvement; we ensure a robust and compassionate staff force who can provide the most effective values based care for our service users

Hours the service operates 24/7

Winners #MHAwards19

Co-Production

  • From start: No
  • During process: Yes
  • In evaluation: Yes

Evaluation

  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Sheffield Health and Social Care NHS Foundation Trust developed a Rehabilitation Strategy in 2013. The aim of the strategy was to appraise current rehabilitation & recovery provision which included over 50 placements for service users in out of city, locked rehabilitation hospitals.

Service users were often cared for in facilities many miles from their home communities, consequently having limited contact with family and friends, or the mental health services with which they were familiar.  Admissions were often lengthy, exceeding expected length of stay by considerable margins.

The cost of these placements exceeded £5,000,000.

Our out of area experience

Our local experience

This shows that implementing our rehabilitation strategy increased service users’ likelihood of discharge and greatly increased the number of people living independently and in less restrictive environments.

Getting a grip on the use of out of area locked rehab

The charts below show the admissions to locked rehabilitation:

Admissions

 

Cumulative total of people in out of area locked rehabilitation

These charts show that the trajectory changed once we took responsibility for the out of town service users and the budget. This reduced the number of referrals out of town and quickly reduced the overall numbers of people out of town

Effective referral and reviewing processes resulted in significant savings and better quality of care however in reviewing how care should be provided in future; Sheffield Health & Social Care NHS Foundation Trust made a move to reinvest to deliver high quality care in the least restrictive environment and The Community Enhanced Recovery Team was established

 

What makes your service stand out from others? Please provide an example of this.

Without the provision of CERT, the service users we work with would have remained in out of city locked rehabilitation hospitals, often many miles away from their homes, family & community

Our close partnership with South Yorkshire Housing Association; through working together we have recognised the importance of a stable place and giving a sense of ownership and safety to a person in order for people to build on their skills and confidence in living in the community and being able to work on other aspects of their lives.

By putting staff wellbeing at the heart of what we do and using a whole team approach in all aspects of clinical provision and service development and quality improvement; we ensure a robust and compassionate staff force who can provide the most effective values based care for our service users

 

 

How do you ensure an effective, safe, compassionate and sustainable workforce?

With a heavy emphasis on value based recruitment the team holds the trust values; respect, compassion, partnership, accountability, fairness and ambition; at its heart. We strongly encourage those with lived experience to apply for posts and a high percentage of the team have at some point in their lives experienced mental health issues or have known and supported someone who has.

CERT is dedicated to staff wellbeing and is invested in supporting individuals in their work. Through the provision of weekly protected time for reflective practice and case formulation each staff member is supported through sharing professional expertise and building psychological frameworks for understanding why service users experience certain difficulties, a shared narrative account of an individual’s life the team can develop plans that originate from discussions together as a team.

Case formulation establishes a space to allow the sharing of team decisions around risk, designed to support positive risk taking. For example, the team are able to hold in mind the risks of completed suicide versus the loss of independence, self-efficacy and coping capacity for each individual.

The meetings build collaborative approaches, which develops effective, consistent responses. Case formulation is embedded in the teams routine practice and links to care planning, identifying staff training and support needs, governance and by inviting colleagues from across the Trust who are involved with the service users care, it places CERT within the wider context of rehabilitation services. A team formulation should therefore be more reliable than individual formulation by a single clinician.

Case formulation is designed to ‘bring the team back’ to our core values and allows the team members to maintain a validating work environment and relationships with service users. Through understanding the meaning in behaviour, and understanding staff members own responses, the staff members receive support and learn to recognise and understand “the desperation behind the behaviour, where it was developed and why” (Isabel Clarke)

Weekly reflective practice groups provide an opportunity for staff to reflect on their work in a safe space. It can provide an outlet for anxieties and frustrations generated by their work and help staff to hold a compassionate view of the service user.  It can help staff to maintain a shared perspective of service users whom they have previously found upsetting, or “difficult” or hard to help and this opens minds to other possibilities, and day to day management and help staff to keep empathy with the service users difficulties.

The reflective practice groups provide support and improve communication within the team. These groups also help to promote a shared view and can improve job satisfaction.

CERT utilises a whole team psychological approach to understanding distress using Emotion Focused Formulation (Clarke 2007), interpersonal relating and communication and risk management for all service users.

By placing an emphasis on ‘everyone inputting’, ‘everyone sharing’, the whole of the clinical team are encouraged to share their experiences and knowledge. The aim is to build and maintain a team dynamic that is valuing, respectful and empowering for all, throughout highly challenging situations that can illicit strong emotional responses.

CERT is equally as dedicated to quality improvement and the same whole team approach is applied in this context and value every individual’s contribution to service improvement and wellbeing.

CERT is committed to personal and professional development, using annual performance review we identify individual’s aspirations for career progression and as such we have excellent links with the recovery & education departments and amongst other courses and qualifications; 8 staff have complete a post graduate diploma.

Over 5 years; 31 people who started as band 3 recovery workers have used their skills, development and opportunities to successfully progress into chosen careers contributing to a compassionate workforce in the NHS. These include

 

  • 7 Mental Health Nurses
  • 1 general nurse
  • 2 midwives
  • 2 Trainee Nursing Associates
  • 3 Assistant Psychologists
  • 3 social workers
  • 1 Clinical Psychologist
  • 3 IAPT (Improving Access to Psychological Therapy) practitioners
  • 3 Occupational Therapists
  • 4 Senior Recovery Workers
  • 1 Research Assistant
  • 1 Art Therapist

 

The team supports a variety of students in nursing, psychology, occupational therapy and art therapy. We have also supported 7 health & social care apprentices and two business and administration apprentices.

 

Who is in your team?

Band 8a         Team Manager                                                         1          1.0

Band 7           Assistant Team Manager                                         1          1.0

Band 8b         Principal Clinical Psychologist                              1          0.8

Band 8a         Clinical Psychologist                                                1          0.8

Band 4           Assistant Psychologist                                            1          1.0

Band 4           Assistant Psychologist/research assistant           1          1.0

Consultant Psychiatrist                                           1          1.0

Band 6           Occupational Therapist                                           1          0.6

Band 5            Occupational Therapist                                           1          0.8

Band 6            Care Coordinators (Nurses)                                   9          8.2

Band 4           Recovery Coordinators                                           4          4.0

Band 4           Governance Officer                                                   1          1.0

Band 3           Team Administrator                                                 1          1.0

Band 2            Team Administrator                                                1          1.0

Band 3           Recovery Workers                                                    37        34.0

 

 

How do you work with the wider system?

CERT works with any service or person that may come into contact with our service users throughout their recovery. This includes joint working with South Yorkshire Police, Sheffield City Council, Charity Organisations, Solicitors, Accident & Emergency, Yorkshire Ambulance Service

Due to the often complex needs of our service users we regularly work with services within Sheffield Health & Social Care Trust. As part of the rehabilitation pathway we are closely linked with our partners.

A vital part of supporting service users to transition to living in the community is a sound partnership with South Yorkshire Housing Association who have developed the Livingwell project to work alongside CERT. The team are able to provide relationships with service users that depart from institutional and often stigmatising association with mental services. This has enabled us to work with people in a very joined up way.

Service users are offered a choice of properties in areas that they have identified, they are supported to decorate and furnish their homes before being supported to develop and increase their independence through tenancy support. Tenancy support workers are able to, again work intensively, mirroring CERT to provide a wrap around and bespoke service.

Both teams work effectively together, sharing information and supporting each other in care delivery and support the ethos of supporting someone to increase independence and consequently decrease their need for support.

South Yorkshire Housing and the Livingwell project

 

This feedback has been obtained from service users about the service that Livingwell provide

Key work sessionsCustomers have said that the key work sessions are the most valued part of the service because staff offer personalised support, they are frequent enough, and reliable.
AttitudeCustomers said that the culture of a can do attitude is very important and this creates a positive attitude. They also said that it is clear to see that staff enjoy their job and they are helpful, pleasant, and positive.
Providing advice and guidanceCustomers have said that the Living Well project is great at giving knowledgeable advice and guidance on finance, personal admin, health and benefits. The support around benefits is particularly valued. Also, customers said that they felt this advice was there when it was needed.

 

 

Do you use co-production approaches?

Co-production has been identified as an area of improvement through our quality improvement forums, learning from the implementation of the psychology groups has been shared across the team with a view to developing in other areas.

In the weekly ‘Psychology Group’ we aim for involving service users and using co-production as much as possible. The service users and staff share the responsibility for preparing and planning the group together. We have an external coach who comes every 5 weeks to support the group in facilitating the ‘planning’ session where we brainstorm different ideas for the upcoming sessions and then vote on the topics for the next 4 weeks – everyone has equal say and we try to include the ideas of the group members who are not able to attend the planning session.

We then share the planning and facilitation of the group between the group members. Although the staff often take a bit more of a lead in planning the groups based on the topics which were chosen, as much as possible, the service users are also involved in planning and facilitating sessions or parts of the sessions, e.g. a recent aromatherapy session where a service user trained in aromatherapy spoke about her oils, using aromatherapy for wellbeing, and gave other group members hand massages. We also often invite external speakers and experts-by-experience to facilitate, e.g. recently a peer support worker spoke about her experience of yoga in her recovery and took us through some yoga practices.

During the group, the staff and the service users all contribute to the group discussions, share experiences and participate in the exercises – this is underpinned by the idea that we can all bring something to the session and recognising the commonality and spectrum of human experiences. The group has a very relaxed and safe atmosphere where everyone’s voice is valued. One recent comment from a new participant in the group was that they could not tell who was ‘in charge’ of the group – demonstrating the efficacy of flattening the hierarchy and creating a democratic, co-produced and supportive group.

 

Do you share your work with others? If so, please tell us how.

The model of care we provide has been shared by our Chief executive and Clinical director at National events and forums. This has resulted in a huge interest from other NHS trusts who aspire to develop a similar model. Sharing our learning has also given us the opportunity to learn and develop from other trusts.

Kate Oldfield, Principal Clinical Psychologist has presented the service model and research to conferences in London, Belfast, Cardiff and Newcastle.

The team are holding a National Conference on the 5th July due to the increasing demand from other localities, interested in adopting a similar model in those areas. To date 17 NHS trusts have booked onto the event.

The model has been presented to ‘get it right first time’ and the Royal College of Nursing.

 

 

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

This chart demonstrates the type of support service users received before, during and after CERT. It evidences that prior to CERT service users had a significant level of support with lengthy and frequent hospital admissions. Though the chart does not demonstrate this, we have also established that even in the community there was a high level of dependency on crisis and home treatment services.

Three service users moved away from Sheffield so we have not been able to gather the data after CERT intervention.

 

Has your service been evaluated (by peer or academic review)?

The team was evaluated by the CQC in May-July 2018

 

 

How will you ensure that your service continues to deliver good mental health care?

The CERT leadership team continuously to improve and develop the team. They work closely with Senior Operational Managers and Service Directors to manage the service within financial constraints.

Clinical Governance Forum’s allow us to appraise successes and areas for development within the team and are then used in a Microsystems approach to implement change.

CERT is a dynamic team which is open to new initiatives such as Personal Health Budgets which has involved direct links to the Integrated Personalised Commissioning Board within the CCG. They are also leading on the introduction of police officer placements to improve relationships and understanding of mental health to deliver a more compassionate approach to their work.

Though a robust operational policy exists to support our work, this focus is on practical aspects of service development. In collaboration with the assistant psychologist/research assistant we aim to provide a comprehensive report to demonstrate the model of service provision so it is replicable in its entirety.

 

 

What aspects of your service would you share with people who want to learn from you?

There were initial concerns raised about potential risks of developing the CERT model, these are summarised as:

  • It does not work and people are readmitted to the acute care system.
  • It does not work and there are many Serious Untoward Incidents.
  • It does not work because people become institutionalised in the community and cannot move on.

These were addressed by a process of positive risk taking with effective monitoring and governance systems in place.

In the last 5 years, and having supported 65 service users who would otherwise have occupied inpatient beds only 7% of the total nights in service has been spent on an inpatient ward.

 

 

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): NHS Sheffield Clinical Commissioning Group

Provided by (e.g. name of NHS trust) or your organisation: Sheffield Health & Social Care NHS Foundation Trust

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status) City of Sheffield and surrounding South Yorkshire and North Derbyshire area

Size of population and localities covered: Approximately 600,000

 

 

 

 

 

 

 

 

 

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